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9. Ongoing Management

Components of ongoing management for successful T2DM care should include the following:

  • Regular follow-up with the health care team (via office visit, e-visit, telephone, labs, etc.) should be scheduled yearly. More frequent visits may be necessary if treatment goals are not achieved.
  • Patients starting or having a major change in their treatment program (such as initiating insulin therapy) may need to be in contact with their care clinician as often as daily until glucose control is achieved, the risk of hypoglycemia is low, and the patient is competent to conduct the treatment program and should ideally not be delayed greater than one week.
  • Perform a targeted history and physical yearly on all patients, with particular attention to the feet, cardiovascular system and blood pressure.

Targeted annual history and targeted physical exam:

– Results of self-monitoring blood glucose validate results at least once a year (e.g., check patient's glucose meter against an office random capillary glucose)
– Adjustments by the patient of the therapeutic regimen
– Frequency, causes and severity of both hyperglycemia and hypoglycemia
– Problems with adherence to therapeutic regimen
– Symptoms suggesting development or progression of the complications of diabetes
– Current prescribed medications, over-the-counter medications, dietary supplements and alternative therapies
– Documentation of eye care specialist exam results
– Alcohol/drug use patterns
– Annually screen for microalbuminuria

  • Assessment for symptoms of depression
  • Weight, body mass index
  • Blood pressure – all patients with diabetic nephropathy should be on either an ACE inhibitor or ARB
  • Cardiovascular – evaluation of preexisting problems
  • Feet (nails, web spaces, calluses, ulcers, structural deformities, protective sensation and shoes)
  • At each encounter, ask if the patient has experienced symptoms of hypoglycemia or low blood glucose, review and educate the patient on appropriate recognition, prevention and management. If the patient has a history of severe hypoglycemia (assistance of another person was needed to treat a low glucose) or has developed hypoglycemia unawareness, evaluate the treatment goals for appropriate safety.
  • All patients with diabetic nephropathy should be on either an ACE inhibitor or ARB unless contraindicated. Consider early nephrology consultation for patients with macroalbuminuria and/or Cr above 1.5 mg/dL.
  • Aggressively control hypertension, dyslipidemia, obesity and protein restriction in all patients with nephropathy.

Specialist dilated eye exam

A dilated eye examination for diabetic eye disease performed by an ophthalmologist or optometrist is recommended annually for patients with T2DM (American Diabetes Association, 2014). Less frequent exams (every two to three years) may be considered in the setting of a normal eye exam. The role of fundus photography is still being considered but doesn't replace a comprehensive exam.

Retinopathy

Prevalence of retinopathy is related to the duration of diabetes mellitus. After 20 years of T2DM, more than 60% of patients have some degree of retinopathy (Fong, 2004). Diabetic retinopathy is estimated to be the most frequent cause of new cases of blindness among adults ages 20 to 74 years.

Up to 21% of patients with T2DM are found to have retinopathy at the time of diagnosis of diabetes mellitus (Fong, 2004). Generally, retinopathy progresses from mild background abnormalities to preproliferative retinopathy to proliferative retinopathy.

Poor glucose control is associated with progression of retinopathy. High blood pressure is a risk factor for the development of macular edema and is associated with the development of proliferative retinopathy (Fong, 2004).

Screening for diabetic retinopathy saves vision at a relatively low cost. In fact, screening costs may be less than the costs of disability payments for those who become blind. Laser photocoagulation surgery is effective in preventing visual loss in diabetic retinopathy.  Studies have shown that retinal examinations by clinicians who are not eye care specialists are not reliable in detecting retinopathy (Fong, 2004; American College of Physicians, 1992; ETDRS Research Group, 1991; Klein, 1987; ETDRS Research Group, 1985; Klein, 1984; Diabetic Retinopathy Study Research Group, The, 1981).

Renal assessment and nephrology

Urinary albumin excretion should be tested annually by a microalbuminuria method. There is racial/ethnic variability with regard to the prevalence of end-stage renal disease, with Native Americans, Latinos (especially Mexican Americans) and African Americans having higher rates than non-Hispanic whites with T2DM (American Diabetes Association, 2004b). If albuminuria is above normal, serum creatinine should be measured (American Diabetes Association, 2004b; Bennett, 1995; Nelson, 1991).

Screening to detect microalbuminuria

Measurement of the albumin-to-creatinine ratio in a random, spot collection. Consider early nephrology consultation for patients with macroalbuminuria and/or Cr > 1.5 mg/dL. Aggressive control of hypertension, dyslipidemia, obesity and protein restriction is recommended in all patients with nephropathy.

Several factors can artificially increase the levels of albumin in the urine and should be avoided at the time of the urine collection. These include blood in the urine, prolonged heavy exercise, fever, congestive heart failure, uncontrolled diabetes, severe hypertension, urinary tract infection and vaginal fluid contamination of specimen.

If two out of three screening microalbuminuria tests are positive, the individual has microalbuminuria, and interventions should be considered. A negative finding should be followed annually; a positive finding should be followed periodically, for example annually, to see if the interventions are effective in diminishing the albuminuria (Hannah, 1999; Mogensen, 1996; Bennett, 1995; National Institutes of Health, 1993).

Nephropathy

In T2DM, albuminuria may be present at the time of diagnosis in about 10% of patients, and another 10% later develop it. Progression to renal failure is less certain in type 2 patients than in type 1 patients and appears to be modulated by genetic and other factors.

Patients with clinical nephropathy almost always have retinopathy and coronary artery disease.

Numerous interventions are appropriate at different stages of renal function in order to prevent or slow the progression of renal disease and associated cardiovascular disease, and include (American Diabetes Association, 2004b):

  • Glucose control – Improved glucose control at any stage of renal function reduces renal disease progression.
  • ACE inhibitor or ARB should be used in all non-pregnant patients with micro or macroalbuminuria. For patients with T2DM, ACE inhibitors or ARBs can reduce progression of macrovascular complications (Lewis, 2001; Heart Outcomes Prevention Evaluation Study Investigators, The, 2000). Within one week of initiation, check for elevations in potassium and creatinine levels.
  • Measure serum creatinine at least annually and more often based on stage of chronic kidney disease (CKD).
  • Hypertension control – An ACE inhibitor or ARB should be the initial agent of choice.  Current JNC and NKF/DOQI recommendations call for treatment of blood pressure to < 130/80 in patients with CKD. However, no single, adequately powered intent-to-treat randomized control trial has shown a benefit of this blood pressure goal in CKD (Arguedas, 2013; Appel, 2010; Lewis, 2010). Hence, the recommendation for lower blood pressure goals in all patients with CKD is based on expert opinion and not fully supported by available prospective clinical trials. Determining whether therapy should specifically be titrated to goals lower than < 140/90 mgHg for specific subgroups of CKD patients (e.g., those with moderate proteinuria) should be considered on an individual patient basis, based on clinical judgment and patient preference.

– Cardiovascular risk factor intervention – Dyslipidemia is often present with microalbuminuria and should be treated aggressively. Dyslipidemia may be an independent risk factor for progression of renal disease. Smoking is associated with the onset and progression of microalbuminuria.

– Restriction of dietary protein has been shown to slow progression of overt nephropathy (macroalbuminuria), and there may be some benefit in dietary protein reduction in microalbuminuric patients. In these circumstances, protein intake should be reduced to the adult recommended daily allowance of 0.8-1.0 g/kg body weight per day with microalbuminuria present, and 0.8 gm/kg body weight per day with macroalbuminuria present (American Diabetes Association, 2014).

Treatment for microalbuminuria includes aggressive blood pressure control with ACE or ARB use as first-line therapy, glycemic control, and aggressive cardiovascular risk factor screening and management.

Strongly consider referral to nephrology any patients with a creatinine greater than 1.5 mg, or nephrotic range proteinuria (greater than 3 gm/24 hour).

Patients with a creatinine clearance of less than 30 mL/min should be referred to nephrology for discussions of future options and to enhance the ability to receive a future transplant. These patients also have significant enough renal impairment that they also benefit from more intensive nutritional interventions and proper management of anemia and bone disease (American Diabetes Association, 2004b; Karter, 2002; Lewis, 2001; Heart Outcomes Prevention Evaluation Study Investigators, The, 2000; DeFronza, 1995; Viberti, 1994; Lewis, 1993; Ravid, 1993).

See Appendix B, "Treatment of Diabetic Nephropathy."

Neuropathy

Peripheral neuropathy is difficult to prevent and treat. Most patients with T2DM and peripheral neuropathy have few symptoms. All patients found to have neuropathy should see a foot care specialist for preventive measures aimed at reducing the incidence of diabetic foot complications.

Good glycemic control should be the first control of symptomatic neuropathy.

Comprehensive foot exam with risk assessment

A foot exam should include assessment for the following risk factor for complications:

  • Loss of protective sensation. Protective sensation can be assessed using either a 5.07 Semmes-Weinstein monofilament for light touch or by testing vibration using a 128-Hz tuning fork at the dorsum of the interphalangeal joint of the great toe, or both. Patients with reduced or absent sensation with either of these tests should be educated about their risk and the need for proper foot care to prevent foot complications. See Appendix C, "Using a Semmes-Weinstein Monofilament to Screen the Diabetic Foot for Peripheral Sensory Neuropathy," and Appendix D, "Using a Tuning Fork to Screen the Diabetic Foot for Peripheral Neuropathy."
  • Peripheral vascular disease (absent pedal pulse, history of claudication or ischemic skin changes)
  • Structural deformities (bunion, hammertoes, Charcot deformity, limited joint mobility or prior amputation)
  • Skin disorders (nail deformity, callus, fissure, tinea or ulceration)
  • Footwear (excessively worn, ill-fitting or inappropriate shoes)
  • Medications can improve quality of life in patients with painful neuropathy

Peripheral Vascular Disease

Peripheral arterial disease is commonly associated with diabetes (American Diabetes Association, 2003). As many as 36% of patients with diabetes have lower-extremity peripheral arterial disease based on lower-extremity blood pressure readings. However, a typical history of intermittent claudication or an absent peripheral pulse is less commonly noted.

Initial screening for peripheral arterial disease should include asking about claudication and assessment of pedal pulses. Consider obtaining ankle-brachial index if clinically indicated.

Peripheral vascular disease in combination with peripheral neuropathy places patients with diabetes at increased risk for non-traumatic amputations of the lower extremity. Peripheral vascular disease may be slowed by smoking cessation and treatment of hypertension and dyslipidemia.

Aggressive daily foot care, inspection of the feet at every office visit for diabetes mellitus, early treatment of foot infections, treatment of callus, use of moisturizing lotion and proper footwear may forestall problems, including amputation. Vascular surgery may also prevent amputation in some patients with established severe peripheral vascular disease (American Diabetes Association, 2003).

Proper high-risk foot management is necessary to prevent ulceration and amputation. Consider referral of patients with claudication and/or absent pedal pulses to vascular surgery.

Cardiovascular and Cerebrovascular Complication Assessment

  • History of cardiovascular symptoms such as chest pain, vascular claudication, TIA
  • Cardiac and carotid exams
  • Screening for coronary heart disease
  • Evaluate cardiovascular status before advising increased intensity of exercise (American Diabetes Association, 2004c; Sigal, 2004).

Cardiovascular and Cerebrovascular Disease

Treatment includes control of cardiovascular risk factors (hypertension, dyslipidemia and smoking cessation) and aspirin use. Consider referring patients with known coronary artery disease to cardiology and patients with known carotid disease to a specialist.

Heart failure is also common in patients with diabetes. Metformin may be used in stable congestive heart failure if renal function is normal.

Close monitoring of potassium and renal function is necessary especially if patients have concomitant chronic kidney disease as the common use of diuretics, ACE/ARBs and aldsosterone antagonists in these patients may cause hyperkalemia and worsening renal function. Thiazolidinediones should be avoided in patients with congestive heart failure.

For patients with T2DM, thiazide diuretics in the treatment of hypertension can reduce cardiovascular events, particularly heart failure (Wing, 2003; ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group, The, 2002).

Special Considerations

  • Hepatitis B vaccine should be administered to unvaccinated adults with diabetes who are < 60 years of age. It may be administered to unvaccinated adults with diabetes who are ≥ 60 years of age.
  • Influenza vaccine every year
  • Pneumococcal vaccine – repeat the vaccination once after age 65 if the initial vaccination was given prior to 65. Consider repeating the immunization for those at risk of losing immunity after five years including nephrotic syndrome, chronic renal disease and other immunocompromised states.

For further information, see the ICSI Immunizations guideline.